National MNCH Program Maternal, Neonatal & Child Health Program Ministry of Health, Government of Kashmir, Pakistan Healthy Women, Healthy Family Nighat Z. Khan Setting: Azad Jammu & Kashmir, Pakistan Practicum Director. Dr. K Tracy Site Supervisor: Dr. Muhammad Sabir Khan Abbasi (MBBS, MPH) August 15, 2016
One of my great interests has always been preventive medicine, and within the realm of preventive medicine my focus for the practicum was Women/ Reproductive Health and Child Health as well as nutrition. The issue of reproductive health stems from poor to no access of maternal/reproductive healthcare in low- and middle-income countries, but the issue of reproductive health and the minimal gains made thus far in improving reproductive health, in my opinion is more due to cultural and religious beliefs which is highly correlated with the rights of women. I believe that reproductive health would improve if women, especially teenagers are less guided by cultural and religious pressures and are given adequate education on reproductive/sexual health, maternal rights and women s rights. I was seeking to promote and provide education about modern contraceptive options; promote health-enhancing factors including nutrition, education, sanitation, hygiene, promoting breastfeeding, advocate for childhood vaccination, learn about social factors that contribute to existence of women reproductive health issues. I was also interested in trying to understand the regional health system in place to provide health care to women of reproductive age, assess the nutritional status of women as well as children. For my Practicum, I worked with an organization called Maternal, Neonatal & Child Health (MNCH) in Pakistan. I always had a realization that women of developing countries, and those from rural areas are the ones are in desperate need of education, hence I chose to work with an Organization Called Mother Child Neonatal Health (MNCH) in Kashmir, Pakistan. MNCH works with women of reproductive age in rural area of Kashmir. The organization provided me with access to women in the villages as well as allowed me to be a part of their team for the duration of my practicum.
Via the organization I was able to reach out many regional all-girls secondary schools as well as colleges to provide them education about health-enhancing factors including nutrition, sanitation, hygiene, secondary sexual characteristics, menstruation, managing menstrual cycles, and safe sex practices. I delivered the aforementioned education via seminars at the schools and colleges. I provided intense education about Sexually Transmitted Diseases (Chlamydia, Gonorrhea, Herpes, HIV/AIDS, Human papillomavirus, Pelvic Inflammatory Disease, HIV/AIDS, and Syphilis. Presentation included education about recognizing the signs and symptoms of infections, diagnostic tests and treatment. The seminar was designed to start with power point presentation, followed by a question answer session and then small group discussions. Power point presentations included pictures of all Sexually Transmitted Diseases. I also provided them information about effectiveness of vaccination (HPV, Hepatitis B), I however realized that HPV vaccine is not available in the country. I also utilized Rural Health Centers of MNCH to provide education to women. Again this part of education was also delivered via seminar and presentation. I however had to do more one-on-session at the clinics, as it was difficult to gather a large number of women at a time. There were many religious and cultural restrictions that women face in the region. Focus of my work was to empower women by educating them. I focused on providing women of reproductive age information about contraception options allowing them to make choices about reproduction. Due to cultural barriers, barrier methods of contraception are not as feasible. I also went over conception and complications of pregnancy with women and topics included: recognizing the abnormality, red flags (headaches, blurring of vision, abnormal epigastric pain, bleedings, preeclampsia, eclampsia), most appropriate help to seek in such situations. Most women do not have healthcare during the entire period of pregnancy, I educated
them about the advantages of delivery in healthcare facility or having a Trained Birth Attendant, as MNCH does provide Trained Birth Attendants. I also provided information regarding what they should do in case of home delivery immediate care of neonate. Lastly, I provided mother information about neonatal care and topics included: nutrition (iron supplement, vitamin D etc.), vaccination and neonatal illness. Another objective of my practicum work was to promote breast feeding and child vaccinations. I made pamphlets to handout to women visiting the clinics that contained information about benefits of breast feeding and highlighted the nutritional, economical and health benefits of breast including, as well as bonding and weight loss. I believe I was successfully able to accomplish my goals of providing useful health education to women, and was able to make a difference to an extent. Update on Aims and Rationale: As mentioned previously, my focus for the practicum was Women and Reproductive Health. My goals for the practicum did not necessarily change, I however found myself doing more then what I had expected. There were two occasions where I had to assist in birthing, which was scary and also eye opening experience. I also found myself standing up for the rights of women occasionally. Education is paramount for civil life. What I discovered shocking was that it s not only the men who hinder the education of female child but elder women also interfere and are against educating women. I was told that grandmother, and occasionally mothers are against sending girls to school for two reasons. One, they do not believe that girls can contribute to household income, as they believe that women will never work. Two, they think that education might liberate women and they will be able to think outside the box and will ask for rights and freedom. That was something different for me to witness, as in the past I was of the belief that
only men opposed the education of girls. I believe keeping women uneducated is done systematically to keep them oppressed. Update of Approach, Methods and Findings As mentioned above, Via MNCH organization I was able to reach out many regional allgirls secondary schools as well as colleges to provide them education about health-enhancing factors including nutrition, sanitation, hygiene, physical growth, secondary sexual characteristics, menstruation, managing menstrual cycles, and safe sex practices. I, along with the team of MNCH travelled to different villages to speak to families about vaccination, and participated in Polio eradication program. Using the MNCH healthcare facilities, I was able to reach women of reproductive age to speak to them about conception and complications of pregnancy and topics included: recognizing the abnormality, red flags (headaches, blurring of vision, abnormal epigastric pain, bleedings, preeclampsia, eclampsia), most appropriate help to seek in such situations. I also focused on birth control methods and importance of birth control and benefits of having small families. Based on the knowledge that I have gained from this experience, if I ever had an opportunity to go back to same region, I think I would collaborate with pharmaceutical representatives to accompany me to provide education and information about what birth control options, what prenatal, and multivitamins are available to them. I had to go extra mile to research what birth control options were available, and their financial feasibility to the regional people. If I could, I would like to stay there for an extended period of time, as it is difficult to make a true difference in such short period of time. Locals are very skeptical about foreigners and they also have hard time trusting their motives. I believe that the subset of population ( female) that I focused on are a little better educated about the issues that I focused
on which include nutrition, prenatal postnatal care, better personal hygiene, as well as contraceptive methods. Reflection on the Practicum: It is very easy to become a source of outrage to locals. I had to be extremely careful with the words that I used to speak to locals. I also had to be extremely cautious about presentation material and make sure no materials offends anyone particularly material pertaining to sexually transmitted diseases. I also was much challenged when I addressed the nutrition topic. Due to profound poverty, it was hard to educate and recommend healthy eating. As resources are very limited to many people, and educating them about healthy eating when they have no means of obtaining meat, fruit and multivitamins to mention a few things seemed unproductive without providing them with the resources to obtaining healthy food. Another major challenge that we had to face was with vaccination campaign. Islamic militants oppose vaccination, saying it is a Western conspiracy to sterilize Pakistani children. Polio vaccination teams have been attached and killed by the militants on multiple occasions. When we were out in the field, we had to have police officers accompanying us, but it was still very terrifying as previous attacks were by guns and we did not have bullet proof jackets on. I was petrified and praying that I do not get shot. I was extremely impressed by the MNCH teach and their devotion to work. They get paid minimally (around 100$ a month), yet they stay loyal to their work and risk their lives to deliver vaccines door to door. Another challenge that I faced was the profound lack of education in women and hence lack of comprehension of their health. It was difficult transferring information, or providing education to women, as their comprehension was fairly limited. Despite of all the challenges, I am very grateful for the opportunity that MNCH provided me, and I am glad that I chose to do my practicum in a developing country where healthcare/ public health is facing
major challenges. This experience has changed my perspective on public health practice forever. I see that public health officials have a very challenging road to travel as they are out in the field and are faced with multiple challenges including jeopardizing their lives. I also realized that our healthcare system in North America is very good and we just because have not seen any different take it for granted. I highly recommend this practicum site to anyone who is interested in going abroad and leaning about social and cultural barriers, as well as more hands on experience. They however must have an agenda of their own prior to arriving there. MNCH is excellent at accommodating requests and are very happy to have you there. Conclusion My practicum experience was very rewarding and I left with a sense of accomplishment. Small, but I am certain that I have made a difference by providing good education and understanding of health to the set of people I focused on. I however believe that there is much that needs to be done to promote public and women health particularly. There is substantial amount of gender inequality, discrimination against women, and early and forced marriage. Women in the area the still traded for multiple reasons. It is challenging for an outsider to work there for number of reasons including but limited to language barrier, cultural difference, and trust. People are more inclined to trust physicians as opposed to public health specialist. The entire experience was enlightening, and I would like to go there any chance that I get. It was tough setting, but learning is great, as not only you learn the about the public health issue, but also learn about the social religious and cultural factors that affect the public health.